Healthcare organizations are taking a deep dive into healthcare data to personalize care for underserved patients.
Data analytics may seem like a cold, heartless concept, but healthcare organizations are learning how to use data to deliver more compassionate care.
For Robert Paeglow, MD, founder, president, and medical director of Koikonia Primary Care in Albany, New York, compassionate analytics involves using patient information to build a complete healthcare model, identifying and addressing gaps in care. That's especially important to underserved populations such as dual-eligible patients, who might be getting a fraction of the care they need because they only visit a doctor for an immediate health concern.
"You have to be able to understand all that the patient has to deal with in order to be effective," he says. "We can all read a medical textbook, but what good is it if you don’t understand what the patient is going through?"
Paeglow has been practicing medicine for more than 20 years, growing up around and serving some of the poorer neighborhoods around New York's capital city. And while he says he's "not a computer guy," his practice has used an EHR for more than a decade.
Like many care providers, there's a challenge not only in gathering data through the EHR, but it's also putting it to use. And with the spotlight now on health equity and addressing social determinants of health, the emphasis is on finding the right data to impact patient care.
Paeglow's medical practice gets some of its guidance from Belong Health, a digital health company that works with hospitals and health plans to improve what it calls patient-centered care. Belong Health is one of several companies focused on extracting and analyzing data to improve Medicare Advantage and dual-eligible programs.
Mac Davis, the company's vice president of analytics and growth, says providers often need help pulling together information for complex populations.
"It's really our job to make numbers work for people rather than making people work for numbers," he says. "Numbers tend to make healthcare faceless and dehumanize the patient. [Healthcare providers] need analytics that understand value and humanize that process."
But what does that mean? To Davis, it means understanding where and why complex-care patients aren't getting the care they need. Coordinating care with different providers, such as specialists, may be too complicated, or there may be barriers to accessing care, such as work, family or transportation. That's where the gaps occur, and where patients become disenfranchised with the healthcare system.
To coordinate and manage care for those patients, Davis says, providers need to integrate care into daily life and make it easy to access. That means staying close to home.
"Healthcare is very local for these populations," Davis says. "It has to be."
Paeglow, known to his staff, colleagues, and many of his patients as "Doctor Bob," is that connection. He's the first and often only healthcare contact for his patients, and a trusted resource. And Koikonia Primary Care was founded to be that resource for poor and marginalized populations.
"You kind of want to be like Cheers, where everybody knows your name," he says.
But with that name comes a responsibility.
"We're providing healthcare on a shoestring budget," Paeglow points out. "So it's important that we make it as efficient as possible. But how do we do that and still have that personal touch? We have to make sure the resources we have matter to them."
Paeglow says he and his colleagues hold weekly staff meetings to go over the information, identifying trends and predictors that they can address with their patients. They look for specific data points that they can translate into actionable information, targeting issues like diet and exercise, medication adherence, blood pressure, and blood sugar.
"We need [that information] to refine our programs so that they can be more effective," he says.
That includes mental health. Being the primary care provider for underserved populations means identifying and addressing those concerns, Paeglow says.
"These people can't go to a psychiatrist if they don’t have access," he points out.
At Belong Health, Davis says they look not only at patient engagement, but specific interactions over longer periods of time. They develop risk stratification models based on those interactions, and the likelihood that someone will react positively to this advice or that suggestion.
"It's how you use them and how you’re adding to these things that makes a difference," he says. "The ultimate goal of medicine is that people can live their lives outside of medicine … so you’re looking for [interventions that make an impact.]"
Davis says compassionate care is a journey. Built into that strategy is the idea that providers and patients are collaborating on that journey. Patients will stay engaged if the information they get from their care providers is meaningful and effective. Conversely, if the information doesn't mean much, or doesn't produce results, they'll tune out the doctor or nurse, ignore advice, and skip scheduled appointments.
"This compassionate analytics approach is really about building trust," he says.
Paeglow agrees.
"We're like the linchpin that holds everything together," he says. "At the end of the day, it's all about the data you have and can use. And I can't imagine working now without this."
A new American Hospital Association report takes a closer look at the biggest challengers to healthcare's status quo, and challenges traditional providers to be innovative to survive in a competitive primary care market.
The primary care landscape, which accounts for some $260 billion in annual healthcare spending, is ripe for transformation. The growth of direct-to-consumer telehealth and the retail healthcare industry are putting traditional providers on notice: Embrace innovation or fade away as consumers take their healthcare elsewhere.
To understand how to offer primary care in this chaotic landscape, healthcare leaders might do best to look at how disruptors are entering the space. That's the gist of a report from the American Hospital Association, which cites a Bain & Company analysis that indicates 30% of that primary care market could be owned by those non-traditional providers within seven years.
The AHA's "Health Care Disruption: 2023 Outlook" examines how seven of the biggest disruptors--Amazon, CVS Health, UnitedHealth Group, the Walgreens Boots Alliance, and Walmart, and tech companies Apple and Google/Alphabet—has staked their claim in primary care, and used that platform to expand.
"The nation’s largest retail, payer and tech disruptors once again invested billions of dollars in healthcare in 2022, continuing to build out their visions to transform the field," the report notes. "In the short term, these moves helped the companies grab market share in primary care, concierge medicine, virtual care, in-home medical services and elsewhere."
"In many cases, the investments helped companies broaden their footprints as they continue to integrate their expanding vertical healthcare operations in areas like pharmacy benefits management, behavioral health, care coordination, diagnostics and therapeutics, and health information technology," the report continues.
It points out that these disruptors are seeing success by addressing pain points and gaps in healthcare that traditional, fee-for-service providers have failed to correct. And in the future, healthcare will continue to see these innovative care models that focus on value-based care by, among other things, offering multi-disciplinary services that address specific consumer concerns at the time, place, and modality that they prefer.
The Disruptors
Amazon may be the biggest of the disruptors, with its proposed purchase of One Medical, pending a review by the US Federal Trade Commission, poised to dramatically shake up the primary care field. But the online giant is also expanding its pharmacy base with RxPass, and boosting diagnostics, therapeutics and disease management capabilities.
But this path forward isn't assured, or easy. The failure of the company's virtual primary care platform, Amazon Care, is still fresh, and the One Medical partnership is still under review. Critics also question whether Amazon can forge partnerships with health systems and scale its primary care service to stay on par with competitors like Walgreens and CVS.
CVS Health, meanwhile, is laying the groundwork to be the biggest primary care provider, capped off by the recent acquisition of Oak Street Health. The company has also picked up Signify Health and is investing heavily in virtual care and digital health, through both its HealthHUB locations and innovative start-ups and early-stage tech companies. With more than 10,000 retail pharmacies in the US and Puerto Rico, as well as 1,000 MinuteClinics, it's poised to continue growth.
But will the company's reach exceed its grasp? Critics wonder if it's growing too fast, and not laying the right groundwork through partnerships with providers and payers. Management's goal to facilitate 65 billion healthcare transactions by 2030 is a lofty promise.
UnitedHealth Group, which includes Optum, is the one familiar face in the crowd, with a background in the payer market. The company has made a huge push toward diversification, topped off by the $8 billion merger with Change Healthcare this past year and investments in digital health, care coordination and remote patient monitoring capabilities. Now it's focused on value-based care, including an ACO partnership with Walmart, a partnership with HealthEdge and the acquisition of Imperium Health.
And while value-based care is at the top of everyone's to-do list, no one has figured out how to make it work just yet. UnitedHealth Group will have to integrate all of these new partners and programs while also convincing its physicians and members to embrace VBC.
Walgreens Boots Alliance's growth is yet to come, but the company has laid the ground work with its partnership with primary care provider VillageMD and home care company CareCentrix and the acquisition of Summit Health. The company is now poised to expand its presence in the US with co-located primary care practices alongside its pharmacy network, while building out a home healthcare platform.
The big question is whether Walgreens Boots can compete with the likes of Amazon and Walmart and meet its ambitious growth plans. This is uncharted territory for the company, and the best-laid plans don’t always come to fruition.
Walmart, meanwhile, is building on an established base as the nation's largest retailer by adding virtual care, a discount drug platform and even an EHR. The company is betting on its brand and its pharmacies to establish long-term healthcare partnerships, which will be augmented by telehealth services, health centers and enhanced value-based care partnerships. The key to its growth is in creating partnerships with consumers.
But the name and the network won't automatically lead to success. Walmart still has to deliver the kind of healthcare experience that will make customers come back again and again. Like the others, it will have to scale accordingly, and hope it has the resources to support its vision.
Alongside the five retail giants are two technology firms, Apple and Google/Alphabet.
While Apple won't be competing for primary care, the company is aggressively expanding its healthcare platform through devices with the Apple Watch and iPhone, giving payers, providers and researchers new opportunities to connect with the consumer. As Apple continues on this path, it will need to make sure that connection is safe and reliable. The information collected by those devices and used by both consumers and providers has to accurate, meaningful and protected, as well as easy to gather and disseminate.
To expand from that platform, Apple will need to look for other ways to monetize that relationship beyond device sales.
Google/Alphabet has that platform, and will be investing heavily in AI technology and hardware to make healthcare data accessible and easy to use. The company is actively courting the pharma market and investing in technology that enables healthcare organizations to focus on health equity, value-based care and patient engagement. It's also partnering with health systems to tackle specific pain points like radiology support and patient flow.
The question for Google/Alphabet will be whether it can "own" the consumer's healthcare journey and monetize those interactions. Some wonder if the company will expand to include direct care or prescription drugs.
How Can Healthcare Organizations Fit In?
The AHA report concludes with four questions that every healthcare organization should ask:
Do we have an omnichannel presence that provides the convenience, access, transparency, pricing and other information and services that patients want?
Are there partnership opportunities with any of the Big 5 companies transforming primary care?
How can we leverage our strength in established trust and rapport with existing patients to use our outpatient, clinic and virtual services for routine and nonemergent care?
How can we partner with big tech firms around research, data sharing, etc., to improve care?
The implication is clear. Healthcare organizations can't continue with a business-as-usual approach. Consumers are more in control of their healthcare expenses and decisions, and they have the ability to shop around. Likewise, payers and self-insured businesses are looking for better ways to deliver and track healthcare, with the goal of cutting out the tremendous amount of waste that the industry has been supporting for years.
In order to keep up with the disruptors, they may have to be the disruptors.
A new survey commissioned by AHIMA finds that nearly 80% of healthcare organizations are collecting data on social determinants of health, but they're having problems gathering and analyzing the right data, finding trained personnel to do the work and putting that data to use to improve clinical outcomes.
Roughly eight of every 10 healthcare organizations are collecting data on social determinants of health (SDOH), but technology problems are keeping them from using that data to effectively improve clinical outcomes.
That's the takeaway from a new survey commissioned by the American Health Information Management Association (AHIMA) and conducted by NORC at the University of Chicago. The survey, of 2,600 AHIMA members and others, found that providers are facing difficulties standardizing and integrating data, including a lack of training on how to collect, code and use the information. They also are struggling to use the data they have.
“The effective collection, coding, and use of SDOH data are vital to improving health and healthcare outcomes,” Wylecia Wiggs Harris, PhD, CAE, AHIMA's chief executive officer, said in a press release issued by the agency. “Health information professionals play a pivotal role in how SDOH data is collected, shared, and ultimately used to improve health and healthcare outcomes. We look forward to collaborating with policymakers, providers, and key stakeholders to advance comprehensive solutions to address the challenges illuminated by this survey.”
The US Department of Health and Human Services defines SDOH as "the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks." This includes home and family, education, work, travel, and digital literacy, among other factors.
Healthcare organizations have been increasingly focusing on SDOH as they shift to value-based care and the concept of treating the "whole patient" on his or her lifelong healthcare journey. That means taking into account and addressing all the factors that affect a patient's health and wellness through programs and partnerships.
But according to the AHIMA survey, that isn't easy. According to researchers, less than 2% of the claims data of Medicaid and Medicare enrollees includes SDOH.
"Despite the increased attention and emphasis on SDOH, there are real challenges to addressing individual social needs, especially within the healthcare system," a white paper issued with the survey points out. "Historically, the healthcare system has not been oriented to address these issues and significant changes are needed to enable healthcare providers to affect health outcomes through the use of this data. While a multitude of changes are needed, a focus on the documentation of these needs and translating those needs into coded data for actionable use is foundational."
According to the survey, some 78% of respondents collect SDOH data, and 71% of them gather it through the EHR, but they prioritize different elements. Only 44% track housing insecurity, 38% eye economic stability, 36% look at food insecurity, 28& look at transportation, and 17% track education.
"These findings suggest that these variables might not have structured fields in the organization’s ’s EHR that would facilitate collection," the white paper notes.
Among other issues, the survey found that while health systems are collecting the data, they aren't necessarily integrating it in to the EHR.
"The fact that the data may be incomplete, unstructured, and/or buried in inconsistent fields -- such as health concerns, goals, social history, etc.— may limit the integration of this information into the EHR," the study reported. "Broader collaboration among key stakeholders across the health care sector is a critical step to improved collection of SDOH data and ultimately using this data to improve health outcomes. Policy can serve as a crucial lever to advance collaboration between stakeholders with the ultimate goal of improving the collection, coding, and use of clinically-relevant SDOH data to improve health outcomes."
To that end, AHIMA is recommending that HHS lay out what SDOH data healthcare organizations should be collecting, and perhaps offer financial incentives for prioritizing that data.
In addition, the organization recommends that the federal government offer financial and technical support to train healthcare providers on how to collect, code, and use SDOH data, including "a focus on cultural competency coupled with the recognition that different care settings may require different approaches."
Finally, AHIMA is recommending that the federal government provide funding, technical resources, and infrastructure to help providers use that data in coordination with other organizations.
"Many of the solutions to addressing SDOH needs rely on collaboration between the health and social services sectors," the white paper concludes. "This type of cooperation is happening in pockets at the local level. Many providers are reticent to ask their patients about their SDOH needs without first having the community-based support system to which they can refer the patient so that these needs can be met. Federal incentives are needed for states to create better alignment—across coordinating agencies to improve coordination, collection, and, ultimately, impact."
Six healthcare organizations have been selected to implement and test the TEFCA standards as the next step in becoming Qualified Health Information Networks (QHINs), the latest stage in the development of a nationwide healthcare information exchange.
Federal officials have named six healthcare organizations as qualified to implement the Trusted Exchange Framework and Common Agreement (TEFCA), the latest step in the effort to create a nationwide healthcare information exchange.
At a news conference Monday, US Health and Human Services Secretary Javier Becerra presented certificates to the CommonWell Health Alliance, eHealth Exchange, Epic TEFCA Interoperability Services, Health Gorilla, Kno2, and KONZA. Those organizations are now qualified to implement and test TEFCA standards on their way to being designated Qualified Health Information Networks (QHINs).
"This is a significant step for the US health system and one that will advance interoperability at scale for patients, health care providers, hospitals, public health agencies, health insurers, and other authorized health care stakeholders," Micky Tripathi, PhD, the HHS' National Coordinator for Health IT (ONC), and Mariann Yeager, CEO of the Sequoia Project, said in a blog. "Strong privacy and security protections are required of QHINs and their expanded connectivity will help improve the quality, safety, affordability, efficiency, and equitability of health care across the country. Nearly every American that uses the health care system will eventually experience the benefits."
Tripathi and Yeager, whose organization is the TEFCA Recognized Coordinating Entity, said the six networks cover most the nation's hospitals and tens of thousands of providers and process billions of healthcare transactions each year.
Federal officials unveiled the TEFCA guidelines in January 2022, fulfilling requirements of both the 21st Century Cures Act and HITECH Act that called for a clear infrastructure model and governing approach for a nationwide health information exchange. The Trusted Exchange Framework is a set of non-binding principles for health information exchange, and the Common Agreement is a legal contract that highlights those principles.
The Sequoia Project will sign the Common Agreement with each QHIN, after which the QHINs will set up the new connectivity framework, using as a guide the QHIN Technical Framework, which lays out the functional and technical requirements. At the same time, the ONC and Sequioa Project are also developing a TEFCA Health Level Seven (HL7) FHIR Roadmap to ensure interoperability.
Washington's MultiCare Health System is using a technology platform positioned above the EHR to match patients with clinical trials run by its Institute for Research & Innovation.
For busy clinicians, determining whether a patient makes a good candidate for a clinical trial is often low on the list of things to do during a healthcare visit. But AI technology is making that process much easier, and opening the door to potential life-changing health outcomes.
The MultiCare Health System, a Washington-based network of 12 hospitals, has been offering a robust slate of clinical trials through its MultiCare Institute for Research & Innovation for almost 40 years, but the process of matching patients to trials isn't easy. Clinicians have to be on top of all the trials underway and each program's inclusion criteria, then they have to comb through a patient's medical records to see if the patient would make a good candidate.
Recently, the health system launched a digital health app for oncology and pediatric practices that does the hard work for clinicians. It sits above the EHR, pulling out patient data to match patients to ongoing clinical studies, then sending alerts to care providers on those matches.
"When a physician introduces a clinical trial opportunity to a patient … we have a lot more success in engaging that patient in a clinical trial, and that increases the chances" of a meaningful outcome, says Annie Reedy, CRA, MBA, MultiCare's chief research and education officer. "When you’re nudging the physicians [with an app that says] this patient may be a good candidate, that's a much better way of working it into their workflows."
Annie Reedy, CRA, MBA, chief research and education officer, MultiCare Health System. Photo courtesy MultiCare Health System.
Clinical trials have long existed in a different orbit than clinical treatment, with few opportunities to bridge the gap unless the provider is personally involved in the clinical trial. Surveys have found that about 90% of doctors would feel comfortable referring a patient to an appropriate clinical trial, but less than 1% are doing it, often because they're just too busy to keep track of all the available trials.
This, in turn, has affected how these trials are conducted. If clinical trials aren't gaining access to the best candidates, only those who've been able to register, the chances of meaningful results diminish. And if a trial doesn't have a diverse and equitable patient base, especially underserved populations, there's a less of a chance of creating a treatment that will help patients who need it the most.
Reedy points out that many therapeutic clinical trials also have strict inclusion and exclusion criteria, making it difficult to find the right candidates. In addition, research tends to be focused on research institutions, rather than health systems with diverse patient populations.
"Access to many of these trials is very, very tough," she says. "That's why you need tools to make that process easier."
MultiCare is partnering with Alabama-based IllumiCare to deploy the company's Trials App, part of the company's Smart Ribbon platform. The technology sits above the health system's Epic EHR, pulling out and analyzing the necessary information and sending alerts to providers.
Reedy says MultiCare's Institute for Research & Innovation is currently involved in about 120 clinical trials, including new trials recently launched to address pediatric migraines and adult diabetes. The health system enters inclusion and exclusion criteria for each of those trials into the platform, which then sifts through the health system's patient base for candidates.
That, she adds, is much more efficient than the old process, in which trial coordinators combed through medical records looking for the right matches. That process was time-consuming and labor-intensive and not always accurate.
"This saves a lot of time and effort," she says, and is much more comprehensive.
Aside from picking the right patients, the process is set up so that the patient's care provider can recommend the clinical trial, which is important. Reedy notes that patients are much more likely to heed their doctor's advice on taking part in a clinical trial, and are much more likely to engage in the trial and stay motivated. This, in turn, improves the effectiveness of the trial.
MultiCare Health is one of the front-runners in adopting IllumiCare's technology, but there are several vendors in the space with different platforms—and plenty of room for expansion. Reedy says the health system is currently set up to screen and recommend only its own clinical trials, and a natural expansion of the platform would take in other clinical trials. That, like any health information exchange program, will take time and involve more sophisticated technology.
Closer to home, Reedy would like to expand MultiCare's platform so that it could not only link patients to clinical trials, but other care management education and resources, especially for patients who opt out of clinical trials.
The University of Virginia Health System is using a federal grant to expand stroke treatment and telehealth training, as well as access to its iTREAT telestroke platform, to six rural Virginia counties.
The University of Virginia Health System is spearheading a new digital health program aimed at improving emergency treatment of strokes in rural areas.
UVA Health is using a $1.5 million grant from the US Health Resources and Services Administration (HRSA) to launch a three-year telemedicine program to educate and train rural healthcare providers on pre-hospital emergency care and post-discharge follow-up care for stroke patients. The program will also link ambulances in those counties to the health system's iTREAT telestroke platform, which connects EMS crews treating a suspected stroke victim in real-time with specialists.
"This will help us render excellent care not only for sudden strokes but also for the prevention and follow-up treatment of stroke,” Nina Solenski, MD, a stroke neurologist at UVA Health’s Comprehensive Stroke Center and the program’s director, said in a press release. “This is urgently needed. Buckingham County, for example, has nearly twice the rate of stroke deaths in non-Hispanic Black individuals compared to the national average. Reversing these types of disparities in our own surrounding communities is our goal and it’s a team effort with all different types of healthcare providers.”
The program's training element will focus on three areas. Paramedics and other EMS providers will be given instruction on community paramedicine strategies, which will enable them to treat more 911 calls at the scene and reduce unnecessary ED transports. Through a Project ECHO telemedicine platform, they'll be educated on the latest methods for identifying and treating patients suspected of suffering a stroke from specialists. And they'll also be taught how to use telemedicine for stroke treatment and care management.
“This is an important goal of the program," George Lindbeck, MD, an emergency medicine physician at UVA Health and the program’s co-director, said in the press release, noting the education resources will also be made available to students at the Charlottesville-Albemarle technical Education Center and nursing students at UVA Wise. "We want to encourage the development of these trainees and get them excited about joining a team of technology-savvy healthcare professionals dedicated to ensuring healthy lives for all.”
One of the longer-running and most documented telemedicine services, telestroke has been proven to boost clinical outcomes and save lives in both urban and rural regions. The service centers on a secure and reliable audio-visual telemedicine platform that gives emergency responders an on-demand link to a stroke specialist who can identify and diagnose stroke symptoms and prescribe clot-busting drugs. The sooner that a stroke id diagnosed and those drugs are administered, the better chance the patient has of avoiding brain damage and death.
The platform is widely used in telemedicine programs that link smaller, rural hospitals and healthcare sites to a larger hospital with stroke speciialists, with the goal of improving clinical outcomes in rural and remote areas where it takes much longer to reach a specialist and administer medication. Some cities and health systems have also used vehicles fitted with telemedicine technology and deployed solely for stroke vicitims, though the price tag for those vehicles is high. As the technology improves, a more likely approach will be to include telemedicine in ambulances and EMS vehicles.
More than 95% of certified healthcare IT developers met last year's deadline to upgrade interoperability standards as mandated in the Cures Act Final Rule, according to the agency.
More than 95% of certified healthcare IT organizations met last year's deadline to upgrade application programming interfaces (APIs) to new federal standards, according to the Health and Human Services Department's Office of the National Coordinator of Health IT.
In a blog issued this week, Rob Anthony, director of the Certification & Testing Division in the Office of Technology, said the upgrade to new certification standards mandated in the Cures Act Final Rule "will have long-lasting impact for patients, clinicians, and certified health IT developers." Specifically, those changes:
Advance interoperability for patient and providers through the use of FHIR-based APIs;
Ensure that electronic prescribing is reliable and complete; and
Give all stakeholders a common and visible view into Real World Testing plans, through which certified healthcare It developers test their technology in real-world settings.
"These new criteria make it easier for patients to access their own health IT record from mobile devices, allow electronic health information to flow more freely between health IT systems, and provide enhanced privacy and security for health IT," Anthony said in the blog.
According to the agency, 646 product listings from 411 developers met the deadline to update to 2015 Cures standards by the end of 2022.
"As part of a new dynamic for the Certification Program finalized in the Cures Act Final Rule, our requirements for standardized APIs included a provision to update certified API technology previously certified to § 170.315(g)(8) to FHIR-based APIs in 170.315(g)(10) as well as provide that updated certified API technology to customers by December 31, 2022," Anthony continued. "These provisions are intended to ensure that providers participating in certain [Centers for Medicare & Medicaid Services] payment programs, such as the Merit-based Incentive Payment System, are able to successfully deploy and use FHIR-based APIs by September 30, 2023."
Anthony said the ONC will now turn to monitoring adoption and conformance through its Lantern platform, and will provide updates throughout 2023.
While some waivers have been extended for two years, other freedoms—including an important Ryan Haight Act provision—will end soon, forcing some providers to take action now.
With the Biden Administration announcing the end of the COVID-19 public health emergency (PHE) on May 11, healthcare organizations are assessing how their digital health and telehealth programs will be affected. While Congress put in place a temporary reprieve in its budget bill, certain freedoms and waivers will end soon.
"This is going to be a trying time" for health systems, says Jacob Harper, a partner in the Morgan Lewis law firm who focuses on the healthcare industry. "It's kind of a double-edged sword. Without knowing [what will happen with the extended waivers], it's really hard to evaluate what the future looks like when you don't know the long-term outcomes."
When the PHE was created in January of 2020 to help the nation deal with the growing pandemic, a number of waivers and exemptions were put in place by federal and state regulators to help healthcare organizations expand and be reimbursed for digital health and telehealth services. The idea behind this was to allow providers to use virtual and connected health tools and platforms to reduce the spread of the virus and make sure consumers were able to access needed healthcare services.
As a result, telehealth use soared during the height of the pandemic, as providers launched new services and programs and consumers enjoyed the benefits of virtual on-demand healthcare. While in-person care is mounting a comeback, health systems are now adjusting to hybrid workflows that allow for in-person and virtual care.
But many programs are buoyed by those PHE waivers, especially those launched by the Centers for Medicare & Medicaid Services (CMS). A growing concern among healthcare executives is that many of these new programs won't be able to stand up on their own without the waivers or new regulations that improve telehealth use and coverage. Those programs may have to be shut down, cutting off patients from important healthcare services.
With the recent Congressional passage of the Consolidated Appropriations Act of 2023, several of those CMS waivers have been extended until the end of 2024. The wavers include that::
Healthcare providers can bill Medicare for telehealth services regardless of the location of both the patient and provider (including the home)
Audio-only telehealth services, such as phone calls, are reimbursable
Federally qualified health centers (FQHCs) and rural health clinics (RHCs) can be reimbursed through Medicare for telehealth services as a distant site provider
Hospice care providers can use telehealth to recertify their eligibility
The list of healthcare providers allowed to bill Medicare for telehealth services is expanded to include physical and occupational therapists and speech language pathologists and audiologists
Members of high-deductible health plans (HDHPs) and health savings accounts (HSAs) can use "first dollar coverage" for telehealth visits without first having to meet a deductible
CMS' acute hospital care at home program remains in place
Harper says this is a reprieve in one sense, but it mainly kicks the can down the road.
"I don't think you can relax," he says, noting those waivers will still end in two years unless CMS or Congress takes further action. "You can't really take your foot off the gas pedal."
Other waivers and freedoms, meanwhile, will end on May 11. Chief among them is a waiver of the Ryan Haight Act's in-person exam requirement. Passed into law in 2008, the Ryan Haight Online Pharmacy Consumer Protection Act severely restricts the prescription of controlled substances, and requires an in-person exam by a qualified provider before those drugs can be prescribed via telemedicine. Enforcement is handled by the US Drug Enforcement Agency (DEA).
Writing in their Health Care Law Today blog, Thomas Ferrante and Rachel Goodman, partners with the Foley & Lardner Law Firm and members of the firm's Telemedicine & Digital Health Industry Team, say the waiver of the in-person exam during the PHE ensured that "millions of both established and new patients were able to receive medically necessary prescriptions via telemedicine."
"There have been efforts to amend the Ryan Haight Act and encourage the DEA to activate the telemedicine special registration rule before the PHE expires, including pending federal legislation," they wrote. "However, to date, the Ryan Haight Act has not been changed and the DEA has not activated the telemedicine special registration rule."
"Thus, when the PHE expires on May 11, without further action on the part of the DEA, the in-person requirement is set to revert, without any special registration rule or other process established to ensure continuity of care," Ferrante and Goodman conclude. "Therefore, continued prescribing of controlled substances for patients never seen in-person, and only through virtual means during the PHE, will be prohibited and these patients would either need to be seen in-person or have their care transitioned to a local provider."
Because the pandemic coincided with—and helped propel—a surge in substance abuse and mental health issues, the last few years have seen a marked increase in telemental health and opioid and substance abuse programs using telehealth and digital health. The key to the success of those programs is the ability to prescribe medications via telehealth.
"I don't know how many of [those programs] are going to survive," Harper says.
Among those calling for action is the American Telemedicine Association (ATA).
"The ATA and [its lobbying group] ATA Action implore our government leaders to provide a sense of certainty to a huge cohort of individuals requiring access to important medications for substance use disorders and other necessary drugs via telehealth after May 11," Kyle Zebley, the organization's senior vice president of public policy and executive director of ATA Action, said in a press release. "Without a plan in place, these vulnerable populations will be left out in the cold, and we are quite sure this is not the intent of our government leaders."
“The ATA and ATA Action have been urging the [DEA] to release its rules for special registration for telemedicine, which will hopefully be a new pathway to continue providing this care post-pandemic," Zebley continued. "However, we are extremely concerned as those rules have been required since the original Ryan Haight Act was passed in 2008 and reiterated in statute by Congress in 2018, but we have yet to see them published. There is now an extreme sense of urgency with the public health emergency ending in only a few months.”
Other changes that will take place with the end of the PHE, according to Ferrante and Goodman, include:
Medicare payment parity. During the PHE, CMS increased reimbursement for telehealth services outside the hospital setting, such as in a patient's home, essentially allowing providers to receive the same payment for a telehealth service as they would for an in-person service. That will end with the PHE, thus reducing telehealth reimbursements outside the healthcare setting. This may prompt some providers to curb their telehealth services or focus more on in-person services.
Telehealth and remote patient monitoring (RPM) co-payment waivers. The US Department of Health and Human Services' Office of the Inspector General (OIG) issued a policy statement during the PHE that they would not enforce sanctions under the Anti-Kickback Statute for cutting or waiving deductibles and co-payments (cost-sharing) for telehealth or RPM services for Medicare patients.
"The guidance documents expressly tie this waiver to the duration of the PHE," Ferrante and Goodman wrote in their blog. "Thus, unless the OIG issues additional guidance or an extension, after May 11, healthcare providers offering telehealth or RPM services to Medicare beneficiaries may no longer reduce or wave any cost-sharing obligations that patients may owe for such services. Digital health companies without payment and collection mechanisms for these payments will need to act swiftly to operationalize new process to ensure these amounts are charged and collected."
RPM program expansion. During the PHE, CMS allowed RPM programs to expand beyond established patients and include (and bill for) new patients. That ends on May 11, and providers will have to conduct new patient evaluation and management services before adding anyone to their RPM programs. This could slow the growth of RPM adoption.
Virtual direct supervision. CMS also changed direct supervision guidelines during the PHE to allow a "supervising professional" to use audio-visual telemedicine to remotely supervise a procedure. CMS did not extend this policy beyond this year in its 2023 Physician Fee Schedule, so virtual direct supervision will no longer be allowed after 2023.
HIPAA enforcement. According to Ferrante and Goodman, the HHS Office for Civil Rights (OCR) relaxed its enforcement of the Health Insurance Portability and Accountability (HIPAA) rules during the PHE, enabling providers to use telehealth in good faith even if they didn't meet HIPAA standards (for example, the use of certain technologies for virtual visits). After May 11, the OCR has said it will resume enforcing those guidelines.
A five-year pilot project launched by California's Medicaid program that addressed social determinants of health in high-risk, high-utilization patients reduced costs by almost $400 per member per year and cut down on ED visits and hospitalizations.
An innovative program designed to improve access to healthcare services for California's most at-risk Medicaid patients reduced per-patient costs by almost $400 per year during the five-year length of the program, according to a new study.
The Whole Person Care program, which ran from 2016 to 2021, enrolled 247,887 Medi-Cal members, according to a review by the UCLA Center for Health Policy Research. Run through 25 pilot projects covering 26 counties, the $3.6 billion program connected participants not only with primary care and mental health care providers, but more than 500 social service organizations, housing support groups and other resources aimed at addressing social determinants of health.
As a result, the program saw 45 fewer hospitalizations and 130 fewer Emergency Department visits per 1,000 beneficiaries (compared to a control group), and a reduction in Medi-Cal payments of $383 per person per year.
“The Whole Person Care program aimed to promote access to care for the most vulnerable Medi-Cal beneficiaries, and evidence suggests that the program was successful in developing needed infrastructure and delivering services needed to support effective care,” Nadereh Pourat, associate director of the UCLA center, head of its Health Economics and Evaluation Research Program, and lead author of the report, said in a press release. “Patients received more care and had improved outcomes.”
The program is one of many that healthcare organizations across the country are launching to address health inequity by identifying non-clinical barriers to healthcare access, called social determinants of health. Advocates say that by addressing those barriers, providers can improve access and clinical outcomes while promoting long-term health and wellness.
In the Medi-Cal program, the California Department of Health Care Services (DHCS) used a Section 1115 Medicaid waiver called 'Medi-Cal 2020' and targeted high-risk enrollees with complex health concerns who often used emergency care services, including those with substance abuse issues, recently released prison inmates, people dealing with severe mental health issues, and homeless residents and those in danger of becoming homeless.
According to the UCLA report, the program accomplished three primary objectives. It:
"Invested in promoting meaningful and diverse partner engagement and buy-in through consistent communication, consensus on strategic priorities, and/or financial incentives;
Acquired and implemented innovative data sharing platforms needed to support cross-sector care coordination and facilitate data sharing with partners; and
Were successful in developing appropriate infrastructure (e.g., staffing, standardized protocols) and processes (e.g., needs assessment, care plan, referrals) to support effective care coordination."
And while the program reduced ER visits and hospitalizations, it also saw an increase in the use of certain outpatient services, such as substance abuse treatment and specialty care, while also seeing a decrease in primary and mental health care services.
“The results show that such programs help complex patients in different ways, depending on their needs,” Pourat said in the press release. “Most importantly, our findings highlight the overall success of the Whole Person Care program and its potential for improving the lives of high-risk patients.”
School districts across the country are partnering with local health systems and telehealth companies to give students access to primary and chronic care services, along with much-needed behavioral and mental health services.
Healthcare has become a vital resource in schools, alongside the familiar staples of reading, writing, and arithmetic. But schools are moving beyond delivering care through a school nurse or staff member with rudimentary medical training. They're using telehealth and digital health tools to give students and staff on-demand access to healthcare providers, offering everything from primary care to chronic care management and behavioral health services.
Providing telehealth to a school or school district can be complex, often because of the costs involved. Schools don't have a lot of money to spend on healthcare, so they rely on grants, federal and state appropriations, or partnerships with local health systems or telehealth companies.
The benefits are numerous. Access to telehealth in the school can reduce both staff and student absenteeism, improve morale and even boost test scores, while also improving clinical outcomes. In many rural and underserved communities, a school's telehealth program may be the only care provider-for students whose families can't afford or travel to any other healthcare services.
In South Dakota, Avel eCare, a telehealth company spun off from Avera Health, is providing virtual care services to students living with Type 1 diabetes in roughly 100 schools in several states. The program was launched as a demonstration project by Avera Health, the Juvenile Diabetes Research Foundation, and the Helmsley Charitable Trust.
Sheila Freed, RN, BSN, NCSN, Avel eCare's school health director and a nurse with some 20 years of experience, says many rural schools don't have a nurse on hand, don't have the money to hire one and wouldn't be able to find one even if they had the funding.
"There's a huge gap there that someone has to fill," she says. "Some nurses are driving from school to school, maybe 60 to 100 miles a day, and they're spending more time behind a windshield than with a student."
Providing the technology for a virtual visit isn't that complicated. A small room is needed for privacy, and many programs use a PC or laptop to establish an audio-visual connection with a care provider. The Avel eCare program uses a telemedicine device developed by Tyto Care to capture vital signs and other biometrics during the virtual visit.
Freed says the Avel eCare program operates as a hub-and-spoke telemedicine network, with the care provider at one location offering services to a number of schools. The program will train someone at each school on how to use the technology.
"We set up the whole program so that teachers can relax," she says.
That idea extends beyond teachers. With a telehealth program in place, Freed says, providers can not only boost care management for students, but be a resource for school staff and even the student's family, helping everyone within the child's orbit to improve their understanding of diabetes and how to help someone living with the chronic condition.
"Type 1 diabetes doesn't end when the school day is over," she says.
And while the program was set up to focus on students living with diabetes, Freed says they'll treat a variety of health issues. One of the long-term goals of the demonstration project, she says, is to prove the feasibility of a telehealth program for addressing almost any health issue in rural and remote schools where access to care is limited.
Avera Health, the sprawling, 300+ site health system based in South Dakota, is supporting the project through its research branch. As of late last year, the program included schools in the Dakotas, Minnesota, Montana, Nebraska, and even Maine, where Avel eCare providers had to learn about the brown-tail moth rash and tick-borne illnesses to treat students, with other states showing interest as well.
"Health systems should pay more attention to these programs," Freed says. "It's a wonderful match for value-based care. Sometimes there's a bit of a disconnect between school system and local health systems, and these programs can bridge that gap."
While some school districts are partnering with health systems for school-based telehealth programs, others turn to telehealth companies like Hazel Health, a San Francisco-based organization launched in 2015 and now working with thousands of schools across the country.
In Los Angeles, city and state organizations are using telehealth to address the dire need for access to behavioral health services in schools. According to the California Master Plan for Kids' Public Health, more than 284,000 school-aged children are dealing with major depression, and two-thirds aren't receiving treatment.
The Los Angeles County Office of Education, partnering with the LA Care Health Plan, Health Net, and the Los Angeles County Department of Mental Health to make free telemental health services available to more than 1.3 million students in kindergarten through grade 12. With $24 million in funding from the health plans and the Department of Health Care Services' Student Behavioral Health Incentive Program, for the next two years, the partnership has contracted with Hazel Health, which expanded its platform to include telemental health services in 2021.
"We continue to see the devastating impact the pandemic has had on our children's mental well-being. This crisis has called us to collective action," Los Angeles County Superintendent of Schools Debra Duardo said in a Los Angeles Daily News story earlier this week. "As a mental health professional, I am keenly aware that partnerships and collaboration across sectors are necessary to meet our children's needs. We must remove barriers to access and continue our efforts to destigmatize help-seeking around mental health. We must also recognize that physical and mental health is crucial to teaching and learning."
Much of the need for behavioral and mental health services has been driven by the pandemic, which disrupted school-based programs and cut off students from familiar healthcare resources. The Centers for Disease Control and Prevention says more than a third of high school students reported mental health issues in 2022, and according to a School Pulse Panel survey used by the US Department of Education's National Center for Education Studies, more than two-thirds of the nation's schools have increased access to mental health services to address that problem.
“I think people should always ask for help,” SaRiya Parker, an 8th-grade student at Benjamin O. Davis Middle School in Compton, told the Los Angeles Daily News. “If you’re suffering in silence it’s like that drowning feeling when you get in the water and can’t get out. Coming to a school psychologist for help is a good way to get out of the water.”
